This section summarizes the report’s service integration findings and offers ideas for how service integration can be improved through further study and policy development.
The IHHP program models show a gradient of service coordination and collaboration in three areas: (1) housing assistance and housing service coordination, (2) employment service coordination, and (3) medical case management. All four sites provide housing assistance, and all four fund housing coordinator positions, though two contract out that function to community partners. Two sites fund employment coordinator positions, but both are contracted out to community partners. All four sites provided medical case management through coordination with RWP-funded medical case managers.
However, all four IHHP sites are concerned about the potential impact of the Affordable Care Act private health insurance coverage expansions and Medicaid expansion on their clients’ future access to RWP-funded medical case managers. As a payer of last resort, RWP may not pay for duplicate services that are available through other sources. Sites expressed concern that RWP clients who enroll in Medicaid may lose their eligibility for RWP-funded case management. In Maine, for example, RWP’s Part B program recently lost most of its case management clients when it was determined that those services duplicated case management services covered by Medicaid.
- The potential impact of the Affordable Care Act on this HOPWA housing-RWP case management linkage could be significant, and is worth monitoring and researching during the roll out of the implementation of Affordable Care Act coverage expansions in 2014 and beyond.
This study also offered a unique opportunity to observe two different housing-HIV care service integration models operating at the same time in the same program site in two different IHHP locations (PHB and RRHS). In both locations, the IHHP model features a “housing first” approach that funds clients’ housing while reaching out to external medical case management and other support services. The HRSA medical home-based SPNS model in both sites addresses clients’ physical health, mental health, and substance abuse issues first, while reaching out to local HOPWA programs for potential housing assistance. Both programs are made somewhat vulnerable by not funding both housing and HIV care elements. IHHP clients have housing, but rely on medical case management available through their health insurance (i.e., Medicaid) or RWP; conversely, HRSA SPNS clients are housed in an HIV medical home, but HOPWA-funded housing assistance may not be available and the client is waitlisted for housing services.
- There is potentially a third option of service integration that encompasses and funds both housing and HIV care, so that client access to both services is guaranteed. It would be useful to study examples of this third option to understand how it compares to the IHHP “housing first” and HRSA “health care first” models.
Two of the IHHP grants are also adding employment coordination to their integrated housing service models. This is a potentially important service integration model that offers clients an opportunity to move into mainstream housing through employment. In these models, IHHP clients become more financially self-sufficient as they gain housing stability and improve their health. The IHHP sites are challenged, however, by employment service providers who were not familiar with the service needs of PLWHA and were somewhat reluctant to take them on as new clients.
- This three-way model of integration (housing, employment, and health care services) should be studied in more detail, and the model’s effectiveness evaluated.
The IHHP sites were studied early in their grant cycle, at the beginning of their second year of operation. As a result, the programs were not very far along in their community planning activities. The sites have developed First Year Implementation Strategies to bring together groups from public housing, homeless (CoC) services, city planning, and HIV (RWP) service organizations to create community-wide IHHP plans, but noted two challenges that they will have to overcome to succeed. First, local CoC and RWP groups have not typically had a history of working together. Second, some sites felt that the needs of their HOPWA clients had historically been marginalized in both local CoC and RWP planning processes.
- The IHHP sites should be revisited at the end of their grant cycle to see what they are able to accomplish in terms of developing integrated planning processes at the community level.
Finally, this study shows that PLWHA have complex housing needs that cannot always be solved through temporary, short-term assistance from RWP or HOPWA. Some PLWHA may need assistance from both programs to stabilize their housing on a long-term basis. Operationally, RWP planning councils should reconsider past decisions not to fund housing assistance.
- New demonstration projects that are designed to formally integrate HOPWA and RWP housing and HIV care components, or to pool HOPWA and RWP resources into one integrated program, should be considered and researched.